Provider Demographics
NPI:1972591733
Name:BOBO, RUSSELL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WAYNE
Last Name:BOBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 E ELIZABETH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4000
Mailing Address - Country:US
Mailing Address - Phone:970-224-2985
Mailing Address - Fax:970-472-9381
Practice Address - Street 1:1236 E ELIZABETH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4000
Practice Address - Country:US
Practice Address - Phone:970-224-2985
Practice Address - Fax:970-472-9381
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0029916207L00000X
NE26009207L00000X
TXF5473207L00000X
WYTL#1443207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01299163Medicaid
WY102557100Medicaid
COC188298Medicare PIN
WY102557100Medicaid
CO050072293Medicare PIN